| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
287 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
249 |
241 |
$19K |
| D1120 |
Prophylaxis - child |
262 |
262 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,637 |
287 |
$5K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
185 |
185 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$257.40 |